ABO Pediatric Ophthalmology and Strabismus 2 — Questions and Answers
Question 1: A 2-year-old develops intermittent esotropia that becomes constant; cycloplegic refraction shows +4.50 D in both eyes, and the deviation is equal at distance and near. What is the most appropriate initial treatment?
- Bilateral medial rectus recession
- Full cycloplegic hyperopic spectacle correction (Correct answer)
- Bifocal spectacles with +3.00 D add
- Botulinum toxin injection to both medial recti
Correct answer: Full cycloplegic hyperopic spectacle correction
Refractive accommodative esotropia with a normal AC/A ratio is treated first with the full cycloplegic hyperopic correction.
Question 2: A child with accommodative esotropia is aligned at distance with full hyperopic correction but has a 20 PD esotropia at near. Which treatment best addresses this residual deviation?
- Increase the distance hyperopic correction by +2.00 D
- Base-in prisms at near
- Executive bifocal segment bisecting the pupil (Correct answer)
- Patching the dominant eye
Correct answer: Executive bifocal segment bisecting the pupil
A high AC/A ratio esotropia is managed with bifocals, classically flat-top or executive segments set high to bisect the pupil.
Question 3: Which finding is MOST characteristic of infantile (congenital) esotropia?
- Small-angle deviation under 15 PD with high hyperopia
- Large, stable angle with cross-fixation and onset before 6 months (Correct answer)
- Deviation greater at distance than near
- Onset after age 3 associated with diplopia
Correct answer: Large, stable angle with cross-fixation and onset before 6 months
Infantile esotropia has a large stable angle, often with cross-fixation, appearing in the first 6 months and usually with only low hyperopia.
Question 4: A 6-year-old with a right hypertropia has a deviation that increases on left gaze and on right head tilt. Which muscle is most likely paretic?
- Right inferior rectus
- Left superior rectus
- Right superior oblique (Correct answer)
- Left inferior oblique
Correct answer: Right superior oblique
The Parks-Bielschowsky three-step test (right hyper, worse on left gaze, worse on right tilt) points to the right superior oblique.
Question 5: A child has limited abduction of the left eye, with globe retraction and palpebral fissure narrowing on adduction. What is the most likely diagnosis?
- Left sixth nerve palsy
- Duane retraction syndrome type 1 (Correct answer)
- Möbius syndrome
- Brown syndrome
Correct answer: Duane retraction syndrome type 1
Duane type 1, the most common form, has poor abduction with globe retraction on adduction, caused by aberrant innervation of the lateral rectus by the third nerve.
Question 6: Which pattern of eye movement is typical of Brown syndrome?
- Limited depression in abduction with an A pattern
- Limited elevation in adduction, often with a V pattern (Correct answer)
- Limited abduction with an esotropia in primary gaze
- Overelevation in adduction with excyclotorsion
Correct answer: Limited elevation in adduction, often with a V pattern
Brown syndrome comes from a restricted superior oblique tendon-trochlea complex, so the eye cannot elevate in adduction and a V pattern is common.
Question 7: A 4-year-old has moderate anisometropic amblyopia (20/80) that has stopped improving after 16 weeks of glasses alone. According to PEDIG results, which starting regimen is as effective as 6 hours of daily patching?
- 2 hours of daily patching (Correct answer)
- Full-time patching
- 1 hour of weekly patching
- No further treatment, since vision has plateaued
Correct answer: 2 hours of daily patching
PEDIG showed that 2 hours of daily patching gave improvement similar to 6 hours for moderate amblyopia.
ABO Pediatric Ophthalmology and Strabismus 2
A 2-year-old develops intermittent esotropia that becomes constant; cycloplegic refraction shows +4.50 D in both eyes, and the deviation is equal at distance and near.
What is the most appropriate initial treatment?